Management of Safe Anaesthesia - SLCOG national Gidelines...70 SLCOA National Guidelines / Safe...

SLCOA National Guidelines

Management ofSafe Anaesthesia

SLCOA National Guidelines

List of ContributorsDr Ranmali De .S .KulasiriDr Malika De SilvaDr Chandani SooriyarachchiDr Vinodini WanigasekaraDr Damitha Wijewardhana

Contents

List of Contributors 68

Introduction 69

pre operative assessment 70

Minimal resources to administer anaesthesia 75

Checking of anaesthetic machine 79

Minimal monitoring standards 83

Administration of spinal anaesthesia 87

Checking of the level 87

Complications 88

Prevention of endocarditis 92

Guidelines for rapid sequence induction 96

Anaesthetic Record 101

69SLCOA National Guidelines / Safe Anaesthesia

2. IntroductionFacilities and resources for anaesthetic practice may

vary from hospital to hospital. Junior medical officers inanaesthetics are expected to anaesthetise ASA I and IIpatients. These guidelines are to correctly guide and helpthe anaesthetic medical officers. Whenever there is a needfor further clarification and advice, they should not hesitateto discuss with the consultant anaesthetist of the hospitalor the nearest hospital in case there is no consultant coverin the local hospital.

2.1 ASA classification

ASA Grading Grade 1 “Normal healthy patient” (without any clinically

important co-morbidity and without any clinically

significant past/present medical history).

Grade 2 “A patient with mild systemic disease that does not

limit activity”

Grade 3 “A patient with severe systemic illness that limits

physical activity”

Grade 4 “ A patient with severe systemic disease that is a

constant threat to life”

Grade 5 “ Moribund patient”

SLCOA National Guidelines / Safe Anaesthesia70

3. Pre operative assessment

3.1 Introduction

Consultation by an anaesthetist is essential for the medical assessmentof a patient prior to anaesthesia for surgery or any other procedure toensure that the patient is in optimal condition for the procedure. Theseguidelines apply to the care of all patients who require anaesthesia.In unusual circumstances e.g. extreme emergencies these guidelinesmay need to be modified and the reasons for so doing must bedocumented in patients’ records.

3.2 General principles• All patients should be seen by an anaesthetist before undergoing

an operation that requires the services of an anaesthetist. Ideallythis should be the doctor who is to give the anaesthetic.

• The responsibility for ensuring that appropriate pre opassessment has been carried out rests with the most senioranaesthetist for the given operating list.

• If that person is a trainee or non consultant grade advice mustbe taken from a duty consultant.

• All patients should have had a basic physical examination ofthe cardiovascular and respiratory system by a medicalpractitioner

3.3 Purpose of pre-operative assessment

This enables the identification of those patients who require:- Few or no pre op investigation- Targeted investigations, the results of which must be available

when the anaesthetist visits the patient in the immediate preoperative period.

- Further assessment or referral after specific investigations.


3.3.1 Objectives of pre -operative assessment

1. Identify potential anaesthetic difficulties2. Identify existing medical conditions3. Improve safety by assessing and quantifying risk.4. Allowing planning of pre -operative care5. Provide opportunity for explanation and discussion6. Allaying fear and anxiety

3.3.2 The anaesthetic pre- op assessment clinic (ifavailable in your hospital)

- This provides the opportunity for anaesthetist to see thosepatients who have been identified by screening andassessment as presenting potential anaesthetic problems bynon anaesthetic medical officer.

- The anaesthetic pre operative assessment clinic shouldpreferably involve a consultant anaesthetist/ a senior medicalofficer in anaestheasia

- The hospital must be fully resourced with staff and equipmentfacilities for X-ray, ECG, and other pre operative testing.

- Patient should ideally be seen within two weeks beforeadmission for surgery

cPre – Op Clinic

• Patient known to have an anaesthetic problem can be assessedby an anaesthetist

• Preferably run by a consultant / senior MO Anaesthesia• Facilities for relevant investigations should be available• Assessment probably 2/52 prior to surgery


3.3.3 The role of the anaesthetist- The anaesthetist is responsible for deciding whether a patient

is fit for anaesthesia.

- With previously screened healthy patients the anaesthetistmust check the results of screening and other pre op testingon the day of surgery or on the previous day.

- Any test performed pre operatively must be available to andread by the anaesthetist

- The anaesthetist should explain the proposed anaestheticprocedure and advantages and complications of anaesthetictechnique to the patient.

- Discussion of postoperative pain strategy and requirementfor monitoring intravascular lines and other invasiveprocedures should also be done.

The role of the anaesthetist• The Anaesthetist should decide whether the patient is fit

for anaesthesia.• Pre- op tests must be available read by the anaesthetist.• The patient should be explained of the proposed

anaesthetic technique and post op pain strategy


3.4 Investigations• Urine ward test- for all• ECG – all with HT/IHD/DM/ CVA/ valvular• HD o Male >40 yr o Female> 50 yr• Full blood count o Males > 40 yr o All Females o All moderate and major surgery o If anemia is suspected

• Fasting blood sugar o Age >40 yr o Obesity o Known diabetic or F/H of DM o Steroid therapy o Non healing ulcers

• Chest X- ray o CVS and RS disease o Risk of pulmonary TB o Malignant disease

• Coagulation screen o History of bleeding disordero anti coagulant therapy o liver disease

• Echocardiogram o cardiac symptoms and signs o Abnormal ECG

• Electrolyte (creatinine if possible) o Age >60 yr o Major surgery o Diuretic therapy o Renal diseases


3.5 Fasting Policies

Minimum fasting guidelines based on the American Society ofAnaesthesiologists:- 6hrs for solid food infant formula or other milk- 4 hr for breast milk- 2 hr for clear non particulate and non carbonated fluids

Patients who have undergone bowel preparations, sick patient,children and breast feeding mothers should not be left for longperiods without hydration. They may require intravenous fluidsprior to surgery.

Minimum Fasting Guidelines

• 6hrs - solid food infant formula or other milk• 4 hr - breast milk• 2 hr - clear non particulate and non carbonated fluids

See preoperative preparation and immediatepostoperative care guidelines for further details


4. Minimum resources that should beavailable when administering ananaesthetic

4.1 Drugs

4.1.1 Anaesthetic drugs• Induction agents – Thiopentone sodium, (Ketamine,

Propofol, Etomidate)• Sedative drugs – midazolam• Analgesics – Pethidine, Morphine,( Fentanyl)• Muscle relaxants – Suxamethonium, Atracurium,

(vecuronium)• Inhalational agents – Halothane• Neostigmine, Atropine• 2% lignocaine (20ml bottle)• 0.5% plain bupivacaine(10ml ampoule)• 2% lignocaine ( 2/5ml ampoule )• 0.5% heavy bupivacaine (4ml ampoule)• Ephedrine (phenylephrine)• Metoclopramide

4.1.2Emergency drugs• Adrenaline 1:1000• Amiodarone, Xylocard• Aminophylline, Hydrocortisone, Salbutamol solution

for nebulisation• Naloxone• Promethazine, Chlorpheniramine• Dopamine, Dobutamine• Calcium Gluconate• Frusemide, KCl• Dexamethasone• 25% dextrose


4.2 Equipment

• Anaesthetic machine

• Adequate number of O2 and N2O cylinders

• Breathing circuits – Mapleson A, D, F and circle

• Anaesthetic ventilator

• Defibrillator

• Multi monitor with NIBP, ECG, SpO2 and ETCO2

or sphygmomanometer, ECG, pulse oximeter and

capnometer separately

• Suction apparatus with suction handles

• Endotracheal tubes of all sizes (number depending on surgical

population)

• Facemasks of all sizes

• Oropharyngeal airways of all sizes

• Tracheostomy tubes

• Laryngeal mask airways

• Two or more functioning laryngoscopes with three sizes

of blades

• Stillettes, gum elastic bougie

• Spinal needles, pencil point type, 25G or smaller

• Syringes – 2, 5, 10, 20ml

• Cannulae - 24 – 14G

• Gloves


4.3Personnel4.3.1 If specialist services are available –

Any child less then 5 years, any patient with significantmedical problems, complicated surgery, needinganaesthesia, the consultant should be informed andfurther plan of action to be discussed and agreed withthe consultant anaesthetist.

4.3.2 If specialist services are not available –There should always be 2 MO anaesthetists whenanaesthetizing children

<1 year – only minor surgery ( I & D).Routine surgery should be transferred to nearest hospitalwith consultant cover.Major surgery if life saving should be undertaken andconsultant anesthetist at closest hospital contacted for anyadvice needed.

1 – 3 years – minor surgery such as I & D could be anaesthetized.Urgent surgery could be undertaken if the MOs are capableand confident of safely anaesthetizing the child. If they areuncomfortable with the situation, they should transfer thechild to the closest hospital with consultant cover.Major surgery if life saving should be done.

>3 years – should be able to anaesthetize most minor uncomplicatedroutine (hernia, hydrocele , circumcision, dermoid cyst )and casualty patients. If anaesthetic or surgicalcomplications anticipated, should discuss with consultantanaesthetist in the closest hospital


Paediatric Anaesthesia

Specialist service available – < 5 years, shouldbe informed to the consultant

Specialist service not available – 2 MOanaesthetists competent in paediatric anaesthesia should alwaysbe available.

<1 year – only minor surgery (I & D).• life saving major surgery – contact consultantanesthetist of the closest hospital for advice• Routine Surgery - Transfer.

1 – 3 yearsUrgent surgery-if the MOs are confidant and

capableMajor surgery if life saving should be done.

>3 years –Minor uncomplicated routine surgery discuss

withconsultant anaesthetist of the nearest hospital ifproblemsare anticipated.


5 Checking the anaesthetic machine

Checking the machine before starting each list is the responsibilityof the anaesthetist. If any problem occurs to the patient (eg.hypoxic brain damage due to O2 failure, delayed recovery due toinadvertent administration of high concentrations of inhaledanaesthetics) the anaesthetist could be held responsible.

Checking the Anaesthetic MachineMandatory before starting each list

• Electrical supply• Gas supply• O2 analyzer• Manoeuvres to prevent delivery of a hypoxic mixture• Flow meters• Vapourizer• Circuits• Monitors• Suction apparatus• Ventilator

5.1Electrical supply – check that the anaesthetic machineis connected to the mains and isswitched on.

5.2Gas supply –Oxygen analyzer if available should be attached tothe common gas outlet.


5.2.1 Pipe line supply-i. Check for O2 and adequate supplies of other gases

(N2O/air).ii. Check that connections are appropriate and confirm

with TUG test.iii. Check all pipeline pressure gauges indicate 400 kPa.iv. Check that the reserve O2 cylinder is available

attached to the machine.

5.2.2 Cylinder supply-i. Open only the O2 cylinder and check the cylinder gauge(136 x100 KPa/136bar).

5.3 O2 analyzer

5.3.1 Open the Rota meter to 6L/min.check analyzer. Shouldreach 100%

5.4 Manoeuvres to prevent delivery of ahypoxic mixture

5.4.1 Turn off the O2 cylinder with the rota meter open, theO2 failure alarm should sound.

5.4.2 Turn on the N2O cylinder 6L/min; check the pressuregauge (50KPa x100/ 50 bar). No gas should flowthrough the O2 rota meter; O2 analyzer should reach50%.

5.4.3. Turn on the O2 cylinder with O2 rota meter still closed,O2 may flow if fitted with a minimum O2 flow device(250ml).

5.4.4 Turn on the N2O rota meter only. See if the O2 flowoccurs at a ratio of 1/3 ( O2 /N2O)


5.5 Flow meters

5.5.1 Ensure that each flow control valve operates smoothly.5.5.2 Ensure the bobbin moves freely throughout its range.5.5.3 Check the operation of the emergency O2 bypass

5.6 Vapourizer-• Ensure each vaporizer is adequately filled• Ensure correct seating of the vaporizer on the back bar,

(not tilted)

5.6.1Check the vaporizer for leak. (with the vaporizer off) bytemporarily occluding the common gas outlet.

5.6.2 Check for leak immediately after changing any vaporizer.

5.7 Circuits – Magill, circle, Bain and Mapleson Fbreathinf systems should

be checked.

5.7.1 Magill circuit-

The pressure relief valve (APL valve) should be closed, and thepatient end is occluded and the oxygen flush pressed. If there areno leaks, the reservoir bag should fill.

5.7.2 Bain circuit-Correct functioning of the Bain circuit is dependent on theintegrity of the inner tube.

• The system must be checked for damage visually. Visualcheck is not sufficientPethick test should be performed before use.


• Pethick test for integrity of the inner tube-1. Fill the bag with the patient port occluded2. Press on the oxygen flush whilst removing the

occlusion3. If the inner tube is intact , the flush of gas from the

inner tube causes collapse of the reservoir bag byventuri effect

4. If the inner tube is not intact, the reservoir bag willfill further

5.7.3 Circle circuit-Check integrity of the one way valves (two bag test)Attach a 2 litre bag to the patient end of the circle systemWith a FGF of 6L/min:Squeeze the bag on the machine:The bag at the patient end should fillOne way valve on the inspiratory limb should open, and oneway valve on the expiratory limb should remain shut. Squeeze the bag at the patient end;The bag at the machine end should fill,One way valve on the expiratory limb should open, and oneway valve on the inspiratory limb should remain shutLeaks in the circuit with the absorber in the “on” positiononly, are due to leaks in the canister, due to overfilling orloose connections.If the leak cannot be corrected the circuit can still be used.But with high flows (5l/min) as given below.

Check efficiency of the soda lime by the colour of the indicator

5.8 Check monitors ( SpO2, ETCO2, NIBP)

5.9 Check suction apparatus is connected to the mains andfunctioning.

5.10 Check ventilator


Connections to mains, alarms andsettings.6. Minimum monitoring standards

Minimum monitoring depends on the type, duration of surgery andpatient factors (ASA III, IV, V)

6.1 The presence of an anaesthetist through out surgery is essentialfor general, regional and monitored anaesthesia.The maintanence of a monitoring chart, with maximum detailsis the responsibility of the anaesthetist.Minimum monitoring includes monitoring clinical parametersand of equipment monitoring.

6.2Clinical monitoring.

6.2.1 Blood and tissue oxygenation by assessing the colour of theblood in the surgical field, mucus membranes or conjunctivaunder good light.

6.2.2 Ventilation- by chest expansion, excursion, tension andmovement of reservoir bag , auscultation of breath sounds.

6.2.3 Circulation- by palpation of the pulse for volume, rate andrhythm, capillary refill time, temperature of extremities, andurine output for extensive surgery.

6.3 Equipment monitoring.

6.3.1 Non invasive• NIBP• SpO2• ECG• ETCO2• Temperature


• Peripheral Nerve Stimulator (PNS).

6.3.2 InvasiveDirect arterial BP, CVP and PAC (pulmonary artery catheter

as required)

Minimum monitoring Standards

• Presence of an anaesthetist• Maintenance of a monitoring chart• Clinical monitoring:

o Colour of the blood in the surgical field, mucusmembranes

o Ventilation- chest expansion, excursion, tension andreservoir bag , auscultation

o Circulation- pulse, capillary refill, temperature andurine output

• Equipment monitoring:o Non invasive

§NIBP, SpO2, ECG, ETCO2 (Mandatory) X§Temp and Peripheral Nerve Stimulator (PNS). Y

o Invasive§Direct arterial BP ,CVP, PAC (pulmonary artery

catheter as required) Z


7. Guidelines for administration ofsubarachnoid anaesthesia for nonobstetric patients

7.1 IntroductionThese guidelines apply to the use of subarachnoid anesthesia.They are intended to encourage quality patient care but cannotguarantee any specific patient outcome. As the availabilityof anesthesia resources may vary, members are responsiblefor interpreting and establishing the guidelines for their owninstitutions and practices. These guidelines are subject torevision from time to time as warranted by the evolution oftechnology and practice.

7.2 Regional anesthesia should be initiated and maintained onlyin locations in which appropriate resuscitation equipment anddrugs are immediately available. :

1) Source of oxygen

2) Equipment to maintain an airway and performendotracheal intubation and suction

3) A means to provide positive pressure ventilation

4) Drugs and equipment for cardiopulmonaryresuscitation

Following drugs should be drawn up, dilutedappropriately & labeledAtropine 0.1mg/ml & Any one of the following drugs

Ephedrine 6mg/ml , Meteraminol 0.5mg/ml Phenylephrine 10mg/500ml n. saline as an infusion titratedto the response


Sub arachnoid anesthesia for non obstetric patients

• Appropriate resuscitation equipment readily available• Draw up and label Atropine 0.1mg/ml, Ephedrine 6mg/ ml, Meteraminol 0.5mg/ml or Phenylephrine 10mg/

500ml N/Saline.• Examine, explain, exclude contraindications and obtain consent from the patient• Intravenous infusion with a cannula (18 gauge or bigger).• Monitoring should be applied

BP, SpO2 , ECG• Communication with the patient• Strict aseptic conditions should be applied

(Mask & cap, scrubbed, gowned & gloved)• Pencil point needles (25 G or smaller)• Check the level of the block• Monitor until post anesthesia condition is satisfactory.

7.3 Regional anesthesia should not beadministered until:

1) The patient has been examined by a qualified medical ` personnel

2) Explained of the procedure and properly consented. An intravenous infusion should be established before the initiation of regional anesthesia and maintained throughout the duration

of the regional anaesthetic (18 gauge or bigger).


7.4 The standards for basic anaestheticmonitoring should be applied

• BP• SPO2• ECG

Communication with the patient should be maintainedthroughout the procedure

7.5 Administration of spinal anaesthesiaStrict aseptic conditions should be applied

• Mask & cap• Scrubbed• Gown & gloves

Pencil point needles with a gauge of 25 or smaller arerecommended to reduce spinal headache.Choice of the local anaesthetic & the dosage may varydepending on the availability, condition of the patient & typeof surgery. Check all the drugs for accuracy & the date ofexpiry before use.The skin should be cleaned with chlrohexidine and spiritsand allowed to dry

7.6 Checking of the level• Appropriate level of block should be achieved

(2-3 segments above the surgical incision).• The level of the block should be checked (with

temperature (cold spray), pain, & touch) beforecommencing surgery

• The anaesthetist should remain with the patientduring the regional anaesthetic until the patient’spost anesthesia condition is satisfactory andstable.

• All patients recovering from regional anaesthesiashould receive appropriate post anaesthesia care;the standards for post-anaesthesia care should beapplied


7.7 Complications7.7.1 Inadequate block• Lower the head end and / remove pillow allow 5-15minutes

& reasses continously

• Supplement with IV sedation, opiates or light GA asappropriate

• Convert to GA

7.7.2 Failed block

• Repeat the procedure

• Convert to GA

• If GA is not feasible call senior help/ postpone

7.7.3 PDPH-(Post Dural Puncture Headache)

ComplicationsInadequate blockFailed blockPost Dural Puncture HeadacheHigh Spinal BlockNerve DamageMeningitis

Signs and symptoms-• Headache usually occurs 12 to 48 hours after the procedure. The

headache is typically described as throbbing in nature in the frontaland occipital regions and may be associated with neck stiffness,tinnitus, deafness, photophobia or diplopia. The defining featureof a PDPH is usually its relationship to posture. It is classicallyworse in the upright position and better or absent in the supineposition.


Management of headache-

• If no headache is present, allow the patient to mobilise. Lyingflat in bed will not prevent the incidence of post-dural punctureheadache.

• If a postural headache develops, encourage oral fluid intake, oralanalgesics, and bed rest. CSF production is not influenced byexcessive fluid intake.

• Consider oral caffeine .As we do not have oral caffeine benzoateconsider giving coffee, tea or coke.

Caffeine is a cerebral vasoconstrictor and has been shown todecrease cerebral blood flow for up to 90ml/min. It may help totreat the cerebral vasodilatory phenomenon that is thought tocontribute to the headache.

• Consider delayed blood patch (20 ml of the patient’s bloodthrough an epidural needle) after 24 hrs if postpartum or if theheadache is severely limiting normal activities.Prophylactic blood patch has not shown decrease in the morbidity.

Management of post-dural puncture headache

o Encourage oral fluid, oral analgesics, and bed rest.o Consider oral caffeine (coffee, tea or coke.)o Blood patch by a consultant anaesthetist..

Procedure:

• Always consult anaesthetic consultant.

• The patient must be apyrexial - otherwise do not perform a bloodpatch.


• Give a full explanation to the patient of the reasons for performinga blood patch. Explain that it is completely successful in 50%and partially in 39 % of patients on the first attempt. The completesuccess rate can go up to 70% if a blood patch is performed forthe second time. Please warn patients that there may be painreferred to the leg or hip as well as back pain during andimmediately after the blood patch procedure.

• Two people are needed, both scrubbed and gowned. Perform anepidural as close to the original puncture site as possible. (MRIscans have shown that a blood patch spreads about 3 segmentsabove and 1 segment below the injection site). When the epiduralspace has been found, take 20 ml of the patient’s blood aseptically.

• Inject 20 ml of blood over 1 minute. The larger the volume thebetter the result. Flush the epidural needle with 2ml of salineafter the injection of blood, prior to the removal of the epiduralneedle.

• Ask the patient to lie flat for 2 hours. Then cautiously mobilise.

• Check the temperature regularly for 24 hours.

• If the headache does not resolve after a blood patch or recursafter an initial successful blood patch, refer to a consultant. A2nd blood patch may be needed. The use of a blood patch doesnot affect the future success of a subsequent epidural block.

7.7.4 High spinal See Obstetric protocol

7.5 Nerve damage


7.7.6. Meningitis

Prevention of Meningitis followingsubarachnoid block

o Strict asepsiso Use only recommended sterile solutiono Follow up until dischargeo Look for fever, unusual headache, neck stiffness,

photophobia and other neurological signs.o If suspected refer to consultant physician/ neurologist

• PreventionStrict aseptic conditions maintainedRecommended sterile solution for SAB should be used0.5% hyperbaric bupivacaine0.5% isobaric bupivacaineFentanylMorphine 2mg /2 ml

• Follow upTo be done until discharge.Look for fever, unusual headache, neck stiffness,photophobia, Signs and symptoms of other neurologicalsymptoms in any suspected patient

• If there is any suspicion of meningitis contact theconsultant physician/ consultant neurologost in thehospital / province


8. Prevention of endocarditis1 in patientswith heart-valve lesions, septal defect,patent ductus, prosthetic valve, or historyof endocarditis

8.1 Introduction

Prevention of endocarditis should always beconsidered in the following conditions. Theseguidelines are adopted from British NationalFormulary, Feb 2006.

• Prosthetic Heart Valve• History of Bacterial endocrditis• PDA• Coarctation of Aorta• Complex cyanotic congenital heart disease• Complex congenital lesions after correction• Congenital cardiac malformations, ASD/VSD,

Bicuspid Aortic Valve,• Acquired Aortic/Mitral Valve dysfunction,• HOCM, MVP with Valvular regurgitation or thickened

leaflets,• Surgically constructed systemic pulmonary shunts.

8.2 Dental procedures2 under local or noanaesthesia


8.2.1 Patients with no special risksPatients who have not received more than a single dose of apenicillin3 in the previous month, including those with a prostheticvalve (but not those who have had endocarditis)Adults : oral amoxicillin 3g 1hour before procedureChildren : 5 - l0 year - half adult dose

Under 5 years - quarter adult dose

8.2.2 Patients with special risksPatients who have had endocarditisAmoxicillin + gentamicin, as under general anaesthesia

Patients who are penicillin-allergic or have received more than asingle dose of a penicillin3 in the previous monthAdults : oral clindamycin4 600 mg 1hour before procedure

Child : 5 - 10 years - clindamycin4 300mg or azithromycin5

300mg

Under 5 years - clindamycin4 150mg or azithromycin5 200 mg

8.3 Dental procedures2 under generalanaesthesia8.3.1 Patients with no special risks

No special risk (including patients who have not received morethan a single dose of a penicillin in the previous month)

adults : i.v. amoxicillin 1g at induction, then oral amoxicillin500mg 6 hours later

child : 5 - 10 years - half adult dose or oral amoxicillin3g 4hours before induction then oral amoxicillin 3gas soon as possible after procedure.under 5 years - quarter adult dose.


8.3.1 Patients with special risksSpecial risk (patients with a prosthetic valve or who have hadendocarditis)

Adults : i.v. amoxicillin 1g + i.v. gentamicin 120mg at induction,then oral amoxicillin 500mg 6 hours later

Child : 5 - 10 years- amoxicillin half adult dose, gentamicin2 mg/kg under 5 years- amoxicillin quarter adult dose, gentamicin2 mg/kg;

8.3.2 Patients who are penicillin-allergic or who havereceived more than a single dose of a penicillin inthe previous month

Adults either i.v. vancomycin 1g over at least 100minutesthen i.v. gentamicin 120mg at induction or 15minutesbefore procedure

Child under 14 years - teicoplanin 6mg/kg. gentamicin2mg/kg or i.v. clindamycin4 300 mg over at least 10minutes at induction or 15 minutes before procedurethen oral or i.v. clindamycin 150mg 6 hours later.

under 10 years- vancomycin 20mg/kg, gentamicin2mg/kg or i.v. teicoplanin 400mg + gentamicin120mg at induction or 15minutes before procedure.

5 - 10 years - half adult dose

under 5 years - quarter adult dose


8.4 Upper respiratory-tract proceduresAs for dental procedures; post-operative dose maybe given parenterally if swallowing is painful.

8.5 Genito-urinary proceduresAs for special risk patients undergoing dental proceduresunder general anaesthesia except that clindamycin is not givenabove; if urine infected, prophylaxis should also coverinfective organism

8.6 Obstetric, gynaecological and gastro-intestinalprocedures

Prophylaxis required for patients with prosthetic valves or those whohave had endocarditis only, as for genito-urinary procedures

1. Advice on the prevention of endocarditis reflects therecommendations of a Working Party of the British Society forAntimicrobial Chemotherapy, Lancet, 1982, 2. 1323—26; idem,1986. 1, 1267; idem. 1990. 335. 88—9: idem. 1992. 339. 1292—93. idem. 1997, 350. 1100: also J Antimicrob Chemother, 1993;31 437—8

2 Dental procedures that require antibacterial prophylaxis are -extractions, scaling, and surgery involving gingival tissues.Antibiotic prophylaxis for dental procedures may besupplemented with chlorhexidine gluconate gel 1% orchlorhexidine gluconate mouthwash 0.2% used 5 minutes beforeprocedure. Oral antibacterial should be taken in the presenceof a dental surgeon or a dental nurse

3 For multistage procedures a max. of 2 single doses of a penicillinmay be given in a month. Alternative drugs should be used forfurther treatment and the penicillin should not be used againfor 3—4 months


4 If clindamycin is used, periodontal or other multistageprocedures should not be repeated at intervals of less than 2weeks; clindamycin is not licensed for use in endocarditisprophylaxis but it is recommended by the EndocarditisWorking Party

5 Azithromycin is not licensed for use in endocarditisprophylaxis but it is recommended by the EndocarditisWorking Party.

Cardiac Conditions that are considered as low risk of endocarditis for which Prophylaxis not recommended

• Isolated secondum ASD• Surgically repaired ASD/VSD/PDA ( without residual defect 6 months after repair)• MVP without regurgitation / Thickened valve leaflets• Physiological / functional murmurs• Cardiac Pacemaker/ implanted defibrillator• After coronary by pass surgery.


9. Guidelines for rapid sequence induction.9.1 Rapid sequence induction is a method of inducing generalanaesthesia in patients who are at risk of aspirating gastric contentsinto the lungs. (induction followed by intubation)

Aim - to shorten the period from loss of consciousness to securingof airway and to minimize risk of regurgitation during this period

9.2 Preparation of the patient• Fasting – There should be an adequate period of fasting where

possible.This should be 6 hours for solids and formula milk, 4 hoursfor breast milk and 2 hours for clear fluids.But in the presence of significant pain and anxiety, there couldbe a delay in gastric emptying even though the fasting time isadequate.

Rapid Sequence Induction (RSI)

• Reduces the risk of aspirating gastric contents into the lungs.• Shortens the time periods from loss of consciousness to securing the airway.

Indications for RSI• Abdominal pathology (intestinal obstruction orileus or any inflammatory pathology)• Delayed gastric emptying (trauma, opioids)• Incompetent lower oesophageal sphincter• Impaired laryngeal reflexes• Neuromuscular diseases• Pregnancy• Autonomic neuropathy as in long standing diabetics


For elective surgery:Ranitidine 150mg and metoclopramide 10mg, orally 2 hoursbefore surgery

For emergency surgery:Ranitidine 50mg and metoclopramide 10mg, i.v. ½ an hourbefore surgery(According to manufacturer’s advice, famotidine should beavoided in pregnancy unless the potential benefits outweighthe risks)0.3M Sodium Citrate solution, freshly prepared, 15 – 30mljust before induction to neutralize the gastric contents

Insertion of a nasogastric tube to remove gastric contents, whereappropriate, such as with intestinal obstruction.

9.3 Preparation of equipment

• Prepare drugs, airway equipment and personnel to assistduring the procedure

• Drugs – pre-calculated dose of induction agent,suxamethonium (1.5mg/kg) and opioid analgesic asappropriate (avoid in Caesarean sections) should be preparedin addition to the emergency drugs

• Equipment – 2 functioning laryngoscopes, range ofendotracheal tubes, oropharyngeal airways, facemasks,laryngeal mask airways and the difficult intubation trolleyshould be at hand. The trolley should be tiltable and suctionapparatus should be switched on at induction.

Antacids and gastric prokinetic drugs should be given. Theconsequences of aspiration depend on the volume and acidityof the gastric contents. Drugs should be given to reduce theacidity and the volume, where ever appropriate.


9.4 Personnel• A person trained in applying cricoid pressure accurately

should be present. (cricoid cartilage should be identified andheld firmly between thumb and middle finger. Index fingershould be usedto apply approximately 20N pressure directlybackwards. Other hand can be placed behind the neck tostabilize it.)

• Procedure should be explained to the patient and cricoidpressure applied with the loss of eyelash reflex. This shouldnot be removed until the trachea is intubated, cuff inflatedand the proper position of the endotracheal tube confirmed.

• If there is active vomiting, cricoid pressure should bereleased to avoid the danger of oesophageal rupture.

• If cricoid pressure is preventing visualisation of the vocalcords and thereby causing failure to intubate, cricoid pressureshould be released.

Preparation for RSI

• Patient· Adequate fasting when possible· Antacids and gastric prokinetics· NG tube where necessary

• Equipment· Airway equipment· Tiltabe table· Suction apparatus switched on

• Drugs· Precalculated dose of induction agent· Suxamethonium 1.5mg/Kg· Opioids as appropriate ( not in pregnancy)· Emergency drugs

• Personnel· Person trained to apply cricoid pressure


Cricoid Pressure

• Should be explained to the patient• Apply with the loss of eyelash reflex• Released only when

Trachea intubatedCuff inflatedProper position of the ET tube confirmed

• Special circumstances to release cricoid pressureActive vomiting ( to preventoesophageal rupture)Cricoid pressure is preventingvisualization of vocal cords

• Position the patient in the best intubating position.

• Attach monitoring and get baseline values.

• Obtain IV access and attach a running drip.

• Preoxygenate the patient with 100% oxygen for 5 minutes or 3 vital capacity

breaths (using Magill breathing system with an oxygen flow of 6L/min.)

• Administer precalculated dose of appropriate induction agent, followed

immediately by suxamethonium.

• Do not manually ventilate but continue to hold the face mask so that 100%

oxygen can enter the lungs due to mass flow until the patient is paralysed.

• Once the fasciculations cease, laryngoscope patient and pass endotracheal

tube through the vocal cords and immediately cuff the tube.

• Confirm proper placement of the tube

• Release the cricoid pressure and turn the anaesthetic gases

Remember to perform a fully awake extubation (in the lateral position if

possible) since these patients are at risk of regurgitation and aspiration during

recovery

Proceudre


To be filled by Ward Staff SurgeonPatient Details Weight Blood group

TempBHT No Ward Pulse Units crossmatched

BPName Urine Analysis

Last Oral IntakeDate of Birth Age Consent for Op

Proposed Operation Mode of Anaesthsia

Preoperative Assessment Allergies

Presenting Complaint AirwayDentitionMalampathyThyromentalNeck movement

CVS

InvestigationsHb

RS RBS

Blood Urea

Serum Electrolytes Other Medical problems Na+

K+

CXRAY

Drugs ECG

Platelet

Previous Anaesthetics PT/APTT/INR

USSProblems anticipated

Pre Anaesthetic Instructions

ASA Grade

Name of the AnaesthetistDate

Anaesthetic RecordTeaching/General/ Base Hospital


Operation SurgeonDrugs

MonitoringSaturationETCO2

Airway PressureAgentTemparatueECGCVP

Vascular Access 200

Peripheral

Central 150

Arterial

100PositionSupineProneLithotomyTrender 50LateralSeated

0Blood LossUrineIV fluid

Pre op deficit CrystalloidsMaintanance ColloidsEvaporation 5% dextrose3rd space loss BloodBlood lossAscitic fluidNG aspirationPleural fluidTotal Total

Fluid loss Fluid intake


Name of Anaesthetist

AirwayFace MaskAirway

NasalOral

LMA size

Tracheal TubeSize

TypeCuff/uncuffOral/Nasal

Throat pack

Laryngoscopy

Ventilationspontaneous

IPPVcircuit

TVRR

I:E RatioO2/N2O/Air

Scavenging

Intra-op Complications: Eye protectionNerve protectionNG TubeDVT prophylaxisTourniquet


Regional Technique

Date Procedure Surgeon Anaesthetist

Consent ComplicationsIV Line FailureMonitoring Inadequate blockTechnique Hypotension Sitting/Lateral level Bradycardia/ Arrythmia

Needle size/catheter size/ c level. High spinal

Cap/gown/mask/gloves/syringes Pruritus

Sensory level Dural tapBloody tap

Drugs RestlessnessOthers

Other treatment/other regional Technique

Post operative Instructions Recovery

Monitoring CVSPulseBP

RSOxygen Airway

BreathingNil by Mouth Spo2

CNSPain relief LOC

Pain

BLEEDINGDRAINS

Complications in recoveryIV fluids

Special Investigations

Date Time

Signatue of N/O

Signature of Anaesthetist

Management of Safe Anaesthesia - SLCOG national Gidelines...70 SLCOA National Guidelines / Safe...

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